Culture is Imperative

On March 23, 2005, a fire and explosion occurred at BP’s refinery in Texas City, Texas, killing 15 workers and injuring more than 170 others. A multitude of equipment failures and human decisions contributed to the disaster. To date, BP’s fines and victim compensation expenses are over $1.7 billion.

One year after the event, BP’s Senior Group Vice President, Safety & Operations, addressed the Second Global Congress on Process Safety.

His concerns and recommendations apply to health care as strongly as they do to oil refining. Lack of a robust safety culture and inappropriate focus on narrow measures each results in management being unable to properly assess organizational safety.

Many organizations struggle with the very same issues he describes below and are susceptible to the same unpleasant surprise that BP experienced.

Take-home messages

  • A robust safety culture is an organization’s primary defense against bad events. All underlying causes discussed below and all but one of the lessons learned are related to organizational culture.
  • Organizational safety measures need to assess overall organizational safety, with the ability to drill down to the overall safety of specific units. Good performance on specific measures, while valuable for addressing a specific problem, may miss big issues. Specific successes may create a false sense of accomplishment.

Excerpt from John Mogford’s speech:

If this was March 22nd 2005 — the day before the explosion — and I was standing here addressing this audience [at the First Global Congress on Process Safety], my remarks to you would have been much different. For a start, my confidence in the BP Group’s safety culture, safety standards, safety management systems and safety audit programs would have been evident. I’d have pointed to some statistics — for example, how in the previous five years the company had reduced its OSHA recordable injury rate by almost 70 percent and its fatality rate by 75 percent. I’d have argued that this positive trend reflected a concerted, systematic approach to safety.… I can only speak for myself but I was shocked by the Texas City explosion. It seemed so out of character with what I believed was BP’s prevailing safety culture. It was hard to understand how such an incident could have happened.…

In the end we identified five main underlying causes:

  • Firstly, over the years the working environment had eroded to one characterized by resistance to change and lack of trust, motivation and purpose. Expectations around supervisory and management behavior were unclear. Rules were not followed consistently. Individuals felt disempowered from suggesting or initiating improvements.
  • Secondly, process safety, operations performance and systematic risk reduction priorities had not been set nor consistently reinforced by management. Safety lessons from other parts of BP were not acted on.
  • Thirdly, many changes in a complex organization — both of structure and personnel — led to a lack of clear accountabilities and poor communication. The result was workforce confusion over roles, responsibilities and priorities.
  • The fourth cause focused on poor hazard awareness and understanding of process safety on the site — resulting in people accepting higher levels of risk.
  • And finally, poor performance management and vertical communication in the refinery meant there was no adequate early warning system of problems and no independent means of understanding the deteriorating standards in the plant through thorough audit of the organization.

And to answer one of the questions I posed just now: many of the safety changes brought in during the previous three years at the refinery with hindsight look incomplete. I think the changes were real and did have impact.… The problem was that they weren’t looking at the whole picture, addressing the whole problem… a kind of tunnel vision.…

With an incident of this scale, the lessons learned are almost endless. But at the facility level seven stand out:

  • The need to ensure plant leadership teams … focus on day-to-day operations …
  • The need to capture the right metrics that indicate [critical] safety trends; do not get seduced by [other] measures, they have their place but do not warn of incidents such as this one.
  • Procedures are ineffective if they are not up-to-date and routinely followed.
  • The importance of two-way communication. If people believe leaders aren’t listening or don’t appear to be taking team members’ concerns seriously, then soon they stop raising them. We must keep our promises to each other. It’s the first step in rebuilding trust and the only way to earn the respect and obtain the commitment of the workforce. This is about staying in touch, being aware, being responsible and listening.
  • The importance of investigating [seemingly minor] incidents … the same way serious injuries are investigated.
  • The value of having an effective feedback loop to capture and incorporate into operating procedures and training programs lessons learned from earlier incidents …
  • And lastly, [prospectively evaluate changes in dangerous areas for unexpected hazards needing mitigation].

… Texas City was a preventable accident but our lessons could help prevent others from falling into the same traps.… Please learn from our mistakes. — Rory Jaffe, MD, MBA,


Mogford J. The Texas City Refinery Explosion: The Lessons Learned.